Complications of Pregnancy 1

Question 1

what is a spontaneous miscarriage?

Answer 1

a termination/loss of pregnancy before 24 weeks gestation

Question 2

list the types of spontaneous miscarriage

Answer 2

threatened
inevitable
incomplete
complete
septic 
missed

Question 3

what is a threatened miscarriage?

Answer 3

This results in vaginal bleeding with or without pain in a viable pregnancy. Upon speculum examination the cervix is closed.

Question 4

what is an inevitable miscarriage?

Answer 4

This is a viable pregnancy, but the cervix is open. Bleeding may be heavy and may have clots.

Question 5

what is a missed miscarriage?

Answer 5

There is no symptoms of this but there may be bleeding/brown loss vaginally. On scanning a gestational sac can be seen. However, the sac is empty with no clear foetus or a foetal pole with no foetal heart seen in the gestational sac.

Question 6

what is an incomplete miscarriage?

Answer 6

Most of the pregnancy is expelled out but some products of the pregnancy remain in the uterus. The cervix is open and there is vaginal bleeding which may be heavy.

Question 7

what is a complete miscarriage?

Answer 7

A complete miscarriage is when all the products of conception (POC) are passed. The cervix is closed, and bleeding has stopped. Ideally it should have confirmed the POC or should have had a scan previously that confirmed an intrauterine pregnancy.

Question 8

what kind of miscarriages are most likely to be septic?

Answer 8

incomplete

Question 9

causes of spontaneous miscarriage

Answer 9

• Abnormal conceptus
o Chromosomal, genetic, structural
• Uterine abnormality
o Congenital, fibroids
• Cervical incompetence
o Primary, secondary
• Maternal
o Increasing age, diabetes
• Unknown

Question 10

management of miscarriage: threatened

Answer 10

conservative

Question 11

management of miscarriage: inevitable

Answer 11

if bleeding may need evacucation

Question 12

management of miscarriage: missed

Answer 12

conservative
medical - PGs (misoprostol)
surgical - SMM (surgical management of miscarriage)

Question 13

management of miscarriage: septic

Answer 13

antibiotics and evacuation

Question 14

what is an ectopic pregnancy?

Answer 14

pregnancy that is implanted outside the uterine cavity

Question 15

ectopic pregnancy: risk factors

Answer 15

PID
previous tubal surgery
previous ectopic
assisted conception

Question 16

ectopic pregnancy: presentation

Answer 16

• Period of amenorrhoea
(with +ve urine pregnancy test)
• +/- vaginal bleeding
• +/- pain in abdomen
• +/- GI or urinary symptoms

Question 17

ectopic pregnancy: common sites

Answer 17

ampullary
isthmus
interstital
ovary
cervix
intraabdominal

Question 18

ectopic pregnancy: investigations

Answer 18

On scanning no intrauterine gestational sac can be seen. It may be possible to see an adnexal mass or fluid in the Pouch of Douglas. Serum BHCG levels, may need to serially track levels over 48hr intervals, if a normal early intrauterine pregnancy HCG levels will increase by at least 66%. With a viable IU pregnancy serum progesterone levels are high at >25ng/ml

Question 19

ectopic pregnancy: management

Answer 19

• Medical
o Methotrexate
• Surgical
o Mostly laparoscopically – salpingectomy, salpingotomy for a few indications

Question 20

what is antepartum haemorrhage?

Answer 20

haemorrhage from the genital tract after the 24th week of pregnancy but before delivery of the baby

Question 21

causes of antepartum haemorrhage

Answer 21

• Placenta praevia
• Placental abruption
• APH of unknown origin
Figure 3 Sites of Ectopic Pregnancy
Figure 4 Ectopic Pregnancy
• Local lesions of the genital tract
• Vasa praevia (very rare)

Question 22

what is placenta praevia?

Answer 22

all or part of the placenta impants in thelower uterine segment

Question 23

placenta praevia: risk factors

Answer 23

multiparous
multiple pregnancies
previous c section

Question 24

placenta praevia classification: grade 1

Answer 24

placenta encroaching on the lower segment but not the internal cervical os

Question 25

placenta praevia classification: grade 2

Answer 25

placenta reaches the inernal os

Question 26

placenta praevia classification: 3

Answer 26

placental eccentrically covers the os

Question 27

placenta praevia classification: 4

Answer 27

central placenta praevia

Question 28

placenta praevia: presentation

Answer 28

painless PV bleeding malpresentation of the foetus incidental

Question 29

placenta praevia: diagnosis

Answer 29

USS to locate the placental site

Question 30

what must you not perform on a woman with placenta praevia?

Answer 30

vaginal exam

Question 31

placenta praevia: management

Answer 31

gestation severity if performing a c-section watch for PPH

Question 32

managment of PPH

Answer 32

• Medical o Oxytocin, ergometrine, carbaprost, tranexamic acid • Balloon tamponade • Surgical o B Lynch cutre, ligation of uterine and iliac vessels, hysterectomy

Question 33

what is placenta abruption?

Answer 33

This is haemorrhage resulting from premature separation of the placenta before the birth of the baby.

Question 34

factors associated the placental abruption

Answer 34

* Pre-eclampsia/chronic hypertension * Multiple pregnancy * Polyhydramnios * Smoking, increasing age, parity * Previous abruption * Cocaine use

Question 35

types of placental abruption

Answer 35

revealed concealed mixed

Question 36

presentation of placental abruption

Answer 36

o Pain o Vaginal bleeding (may be minimal) o Increased uterine activity

Question 37

complications of placental abruption

Answer 37

* Maternal shock, collapse (may be disproportionate to the amount of bleeding seen) * Foetal death * Maternal DIC, renal failure * PPH * Couvelaire uterus

Question 38

general managemnt of APH

Answer 38

``` Management will vary from expectant treatment to attempting a vaginal delivery to immediate Csection depending on: 1. Amount of bleeding 2. General condition of mother and baby Figure 8 Classification of Abruption 3. Gestation ```

Question 39

what is preterm labour

Answer 39

Preterm labour is defined as the onset of labour before 37 completes weeks gestation (259 days). Mildly preterm if born 32-36 weeks, from 28-32 weeks it is known as very preterm, and from 24-28 weeks it is known as extremely preterm. Preterm labour may be spontaneous or induced.

Question 40

predisposing factors to preterm labour

Answer 40

• Multiple pregnancy • Polyhydramnios • APH • Pre-eclampsia • Infection e.g. UTI • Prelabour premature rupture of membranes In the majority there is no cause (idiopathic).

Question 41

managment of preterm labour

Answer 41

Diagnose by identifying contractions with evidence of cervical change on VE. Consider the possible causes such as abruption and infection. • <24-26 weeks o Generally regarded as very poor prognosis o Decisions made in discussion with parents and neonatologists • All cases considered viable o Consider tocolysis to allow steroids/transfer o Steroids unless contraindicated o Transfer to unit with NICU facilities o Aim for vaginal delivery Preterm delivery is a major cause of perinatal mortality and morbidity. It is gestation dependent

Question 42

neonatal morbidity resulting from prematurity

Answer 42

* Respiratory distress syndrome * Intraventricular haemorrhage * Cerebral palsy * Nutrition * Temperature control * Jaundice * Infections * Visual impairment * Hearing loss